Dr Sujoy Sanyal is a conservative spine surgeon by nature which means he exercises utmost restraint in offering surgery to his patients. Only a small percentage of his patients are recommended surgery.
In his practice, he would normally manage Pure Low back Pain without radiation without surgery unless X-rays in flexion/extension reveal instability and/or lumbar spondylolisthesis.
Low back Pain radiating to the leg- Dr Sujoy Sanyal manages conservatively if MRI does not show significant nerve compression.
Low back Pain radiating to the leg- Dr Sanyal offers Surgery ONLY if the MRI shows significant nerve compression.
It is important to get operated at the painful stage rather than after irreversible nerve damage
With continued significant nerve compression, the nerve/s may get damaged resulting in slowly progressive numbness, weakness, loss of muscle bulk in the leg or rarely even sudden onset severe weakness or loss of power in a part of the leg (most commonly foot drop). Sudden onset of severe weakness or loss of power in a part of the leg (most commonly foot drop) does not carry a good prognosis. Even more ominous is damage of the bladder or bowel nerves manifest through slow or sudden onset of symptoms such as urinary retention or urinary incontinence or faecal incontinence.
Therefore, it is imperative that patients undergo identification and surgery at the painful or pareaesthetic stage rather than after developing irreversible nerve damage.
Surgery is done from the back through a tiny incision. Under microscope/endoscope, the surgeon removes all compressing elements on the nerves of the lumbo-sacral spine.
Postoperative recovery-Miraculous disappearance of radiating pain/ paraesthesias
Well-selected patients with severe back pain/paresthesias radiating to the leg have near immediate miraculous disappearance of their pain post-operatively under Dr Sujoy Sanyal. The recovery time is short with most patients walking home the next day.
a. If too much of bone/joint/ligaments need to be removed to adequately decompress the nerves in the lumbo-sacral spine, the strength and stability of the spine might be hampered. In such situations, b. screws are inserted in the vertebral bodies and connected to rods to restore strength/stability to the spine. In addition, cages filled with bone graft are placed between the vertebral bodies in order to fuse one to the other over time, thus buttressing the screws-rods in place.
b. Screws are also required if X-rays in flexion/extension reveal instability in the lumbo-sacral spine which creates a situation called Lumbar Spondylolisthesis.
a. Traditional Open Pedicle Screw Placement
The traditional method of placing screws in the spine is by a large midline incision. Through the midline, first the nerves are decompressed. Thereafter, the muscles are significantly retracted to the sides and screws are placed in the vertebral bodies and connected to rods. Finally, cages filled with bone graft are placed between the vertebral bodies in order to fuse one to the other over time, thus buttressing the screws-rods in place. This method of placing Screws in the Lumbo-sacral spine is termed Open Pedicle Screw Placement.
b. Laparoscopy-style Minimal Access Percutaneous Pedicle Screw Placement
Dr Sujoy Sanyal has stopped placing Open Pedicle Screws for the last 15 years because he finds large midline incisions and retraction of the muscles to the sides grotesque in this era and age. He has placed every screw in the last 15 years percutaneously through tiny stab incisions. He uses meticulous pre-operative planning to ensure exact placement of the screws. Such meticulous pre-operative planning helps exact placement of percutaneous pedicle screws without expensive gadgets such as Neuronavigation/O-arm and also decreases x-ray exposure for both the patient as well as the operating theatre personnel. A small midline incision is used to relieve pressure on the nerves and all necessary screws are placed through tiny stab incisions.
Lumbar Spondylolisthesis is slippage of one lumbar vertebra over the other and happens due to instability. Since the spine is unstable, the slippage continues to progress over time.
The initial manifestation of Lumbar Spondylolisthesis is Low Back Pain/Paresthesias with/without radiation to the legs.
With continued slippage, the weight-bearing capacity of the lumbo-sacral spine gets lowered and lowered, finally result in a bed-bound condition.
With continued significant nerve compression, the nerve/s may get damaged resulting in slowly progressive numbness, weakness, loss of muscle bulk in the lower limb or rarely even sudden onset of severe weakness/loss of power in a part of the lower limb (most commonly foot drop). Sudden onset of severe weakness/loss of power in a part of the lower limb (most commonly foot drop) does not carry a good prognosis. Even more ominous is damage of the bladder/bowel nerves manifest through slow/sudden onset of urinary symptoms such as urinary retention and urinary incontinence.
Therefore, it is imperative that patients undergo X-rays of the lumbo-sacral spine in flexion and extension when they present with significant back pain to diagnose Lumbar Spondylolisthesis.
A. Standard Surgical Treatment of Lumbar Spondylolisthesis and Lumbo-sacral instability
The standard method of surgery is by a large midline incision. Through the midline,
first the nerves are decompressed. Thereafter, the muscles are significantly retracted
to the side and screws are placed in the unstable vertebral bodies and connected to
rods after bringing the vertebral bodies in alignment as much as possible. Finally,
cages filled with bone graft are placed between the slipping vertebral bodies in order
to fuse one to the other over time, thus buttressing the screws-rods in place.
B. Sanyal Minimal Access Surgical How (SMASH) for Spondylolisthesis and Lumbo-sacral instability
This is a path-breaking technique devised to fully reduce the spinal dislocation and fix
the unstable lumbo-sacral spine using small laparoscopy-style incisions for relief of
pressure on the nerves and placement of all the hardware required to fix the
dislocated unstable spine in proper alignment.
Dr Sanyal finds large midline incisions and retraction of the muscles to the sides
grotesque in this era and age. He uses meticulous pre-operative planning to ensure
accuracy of the surgery. Such meticulous pre-operative planning helps safely fix the
dislocated unstable spine in proper alignment through tiny incisions without
expensive gadgets such as Neuronavigation/O-arm.
Small incisions and minimal muscle retraction translate into a quick post-operative
recovery.
Postoperative recovery-Miraculous disappearance of pain/paraesthesias
Patients with severe back pain/paresthesias with/without radiation to the leg have near immediate miraculous disappearance of their pain post-operatively under Dr Sujoy Sanyal. The recovery time is short with most patients walking home within a couple of days.
